Letters to the Editor
Quetiapine May Induce Mania: A Case Report
Dear Editor:
Inducing manic or hypomanic symptoms is a well-documented risk during anti- depressive treatment with different classes of antidepressants (1–3).
Recently, several case reports and a critical review have demonstrated a similar risk induced by atypical antipsychotics, such as olanzapine and risperidone (4). A serotonin (5-HT) receptor occupancy (5-HT2 and 5-HTD2) hypothesis has been proposed to explain olanzapine and risperidone effects on mood (5), but other mechanisms are likely involved in the manic switch that is associated with these 2 atypical antipsychotics (4).
A case report of a woman affected by schizoaffective disorder with quetiapine-associated hypomania has been published. She developed a hypomanic episode after 5 weeks of quetiapine treatment (gradually titrated to 300 mg daily), which receded in 1 week after quetiapine discontinuation (6).
We report a further case of possible induction of manic episode associated with quetiapine treatment in a patient with a schizofreniform disorder.
Case Report
A 23-year-old woman with a DSM-IV diagnosis of schizofreniform disorder was hospitalized for a recent onset of psychotic symptoms, including anxiety, perplexity, and persecutory and somatic delusions. The patient had no history of substance abuse or manic or hypomanic episodes.
From the first day of hospitalization, a treatment with haloperidol 10 mg daily venlafaxine 75 mg daily, and diazepam 2 mg daily was started, but without improvement. Next, venlafaxine and haloperidol were discontinued, and a trial with quetiapine was started and titrated to 400 mg daily over 3 weeks. Gradually, her psychotic symptoms improved, but during the 4th week of treatment, insomnia, hyperactivity, irritability and hostility, elated mood, and grandiosity emerged.
Because of the suggestive temporal relation between the introduction of quetiapine and the onset of manic symptoms in a patient with no history of substance abuse or manic episodes, mania secondary to quetiapine was hypothesized. Quetiapine was discontinued and zuclopentixol and lorazepam were started. Manic symptoms gradually disappeared in the 10 days that followed and did not reappear during the 3-week hospitalization period.
We have described a possible case of mania induced by quetiapine in a patient with schizofreniform disorder. The gradual onset of manic symptoms during quetiapine treatment and the rapid remission with discontinuation of the drug in a patient without a history of mania and without past or current substance abuse seems to support the possibility that quetiapine was responsible for inducing the manic episode. In our case, which is similar to Benazzi’s case, manic symptoms appeared slowly at a moderate quetiapine dosage (6). This seems to support the hypothesis proposed for risperidone, with which quetiapine shares biochemical features; specifically, at high dosages, dopaminergic blockade action shows antimanic properties, while, conversely, at smaller dosages, the mania-inducing effects could result from the 5-HT2 antagonistic action, as well as the ensuing dopamine disinhibiting effects (5).
Although further observations are necessary, clinicians should be aware that quetiapine (as olanzapine and risperidone) may play a role in inducing mania.
References
1. Peet M. Induction of mania with selective serotonin reuptake inhibitors and tricyclic antidepressants. Br J Psychiatry 1994;164:549–50.
2. Altshuler LI, Post RM, Leverich GS, Mikalauskas K, Rosoff A, Ackerman L. Antidepressant-induced mania and cycle acceleration: a controversy revisited. Am J Psychiatry 1995;152:1130–8.
3. Joffe RT, MacQueen GM, Marriott M, Robb J, Begin H, Young LT. Induction of mania and cycle acceleration in bipolar disorder: effect of different classes of antidepressant. Acta Psychiatr Scand 2002;105:427–30.
4. Aubry JM, Simon AE, Bertschy G. Possible induction of mania and hypomania by olanzapine or risperidone: a critical review of reported cases. J Clin Psychiatry 2000;61:645–9.
5. Lane HY, Lin YC, Chang WH. Mania induced by risperidone: dose related? [letter]. J Clin Psychiatry 1998;59:85–6.
6. Benazzi F. Quetiapine-associated hypomania in a woman with schizoaffective disorder (letter). Can J Psychiatry 2001;46:182–3.
Bruno Biancosino, MD; Luciana Marmai, MD;
Anna Facchi, MD; Emanuela Rossi, MD;
Luigi Grassi, MD
Ferrara, Italy
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